The SGAP Flap in Breast Reconstruction: Backup or First Choice?

Abstract

Sir: Deep inferior epigastric artery perforator (DIEP)/transverse rectus abdominis musculocutaneous flaps are typically first-choice procedures for autologous breast reconstruction. The superior gluteal artery perforator (SGAP) flap1 carries substantial fat even in slim women, yet is generally only selected when DIEP/transverse rectus abdominis musculocutaneous flaps are impractical. Few studies have evaluated SGAP outcomes objectively.2,3 This study investigates whether the SGAP flap should be considered a primary rather than secondary option. We reviewed consecutive unilateral reconstructions using DIEP and SGAP flaps performed by one surgeon. Data included age, sex, history of previous abdominal surgery, hospital stay, duration of surgery, blood loss, blood transfusion, type of anastomosis, timing of reconstruction, and follow-up. Outcome measures were flap survival and complications. Complications included hematoma, vascular problems requiring take-back, drain exchange, delayed closure, complete or partial flap loss, cellulitis, congestive heart failure, fat necrosis, and cardiopulmonary arrest. Descriptive statistics were calculated for all variables. Numerical variables were compared using the nonparametric Wilcoxon rank sum test and are reported as medians with interquartile ranges. Categorical or nominal variables were compared using the chi-square test or Fisher's exact test, as appropriate. A line connecting the coccyx to the anterior superior iliac spine formed the axis of the ellipse that defines the SGAP flap and produces a concealed scar. Skin islands measured 10 to 14 cm × 25 to 30 cm. The SGAP flaps were raised on one to two perforators, whereas the DIEP flaps had two to five perforators. Recipient vessels were the internal mammary artery and vein. Over 5 years, 16 SGAP and 24 DIEP flaps were performed. A comparative analysis was conducted (Table 1). The two groups were similar regarding age, length of stay, blood loss, complication rate, and rate of transfusion. The SGAP flap averaged 1 hour longer, 9 hours versus 7.9 hours (p = 0.007). The take-back rate was similar, and all survived. Figures 1 and 2 demonstrate a patient who underwent DIEP flap surgery on her left side and subsequent SGAP flap surgery on her right.Table 1: Comparison of SGAP and DIEP Flap PatientsFig. 1.: Patient who underwent DIEP flap surgery on her left side and SGAP flap surgery on her right.Fig. 2.: The same patient as in Figure 1.The SGAP flap may have greater technical demands than the DIEP flap as reflected by longer operating times. However, some of the time represents intraoperative repositioning. Baumeister et al. examined 81 SGAP flaps and found a 93 percent survival rate.4 They too concluded that the SGAP flap should be considered as a first option, but a direct comparison with other free tissue transfers was lacking. Guerra et al. also found a high “success rate” for the SGAP flap (98 percent survival).3 Subjectively, the SGAP flap patients had less discomfort and, of course, the risks of abdominal weakening, bulge, or hernia were eliminated. Furthermore, the lack of direct “mirror visibility” significantly lowered the patient's awareness of a donor scar hidden inside the panty line. Ample abdominal tissue favors DIEP flaps. However, compromises are made simply to use it. For instance, when tissue is scarce, smaller than optimal reconstructions are accepted and revisionary breast augmentations are performed later. Often, to maximize tissue harvest, more skin is taken, thus preventing a safe tension-free closure. We conclude that the SGAP flap should be considered first for breast reconstruction more often—not simply as an alternate should a DIEP flap fail or be unfeasible. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Arezou Yaghoubian, M.D. J. Brian Boyd, M.D. Division of Plastic Surgery Department of Surgery Harbor–UCLA Medical Center Torrance, Calif.